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Osha State Compensation Form E3067 2010-2023
Compensation
benefits or payments is guilty of a felony.
E
M
P
L
O
Y
E
R
1a. AGENCY CODE OR SCIF POLICY
NUMBER
2. MAILING ADDRESS (Number and Street, City, Zip)
2a. Phone Number
3. LOCATION, if different from Mailing Address (Number, Street, City and Zip)
3a. DIV./LOCATION CODE
4. NATURE OF BUSINESS; e.g., Painting contractor, wholesale grocer, sawmill, hotel, etc.
5. STATE UNEMPLOYMENT INSURANCE
ACCT. NO.
X
Ownership
Industry
Occupation
STATE
COUNTY
CITY
SCHOOL DIST.
8. TIME...
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